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STRAIN &COUNTERSTRAIN
PELVIS AND SACRUM
A PASSIVE POSITIONAL PROCEDURE THAT
PLACES THE BODY IN A POSITION OF
GREATEST COMFORT, THEREBY RELIEVING
PAIN BY REDUCTION AND ARREST OF
INAPPROPRIATE PROPRIOCEPTOR ACTIVITY
THAT MAINTAINS SOMATIC DYSFUNCTION
RATIONALE FOR STRAIN
AND COUNTERSTRAIN
WHAT MAINTAINS THE
SOMATIC DYSFUNCTION?
• COUNTERSTRAIN THINKING IS DIRECTED ESPECIALLY TO THE
• NEUROMUSCULAR REFLEXES
• RATHER THAN THE TISSUE STRESSES
Posterior Lumbar Tender Points
Posterior Lumbar Tender Points
Posterior Lumbar Tender Points
POSTERIOR LUMBAR SPINE
ANATOMY OF THE LUMBAR SPINE
POSTERIOR LUMBAR SPINEGLUTEUS MAXIMUS
POSTERIOR PELVIS & HIP
• HIGH ILIUM SACROILIAC AND HIGH FLAREOUT
SACROILIAC-GLUTEUS MAXIMUS POINTS
Gluteus Max treatmentsneed Extension and Ext Rot
GLUTEUS MAXIMUS (High IliumSacroiliac)
Location of Tender Point: One-and-a-half inches lateral to the
posterior superior iliac spine.
Direction to Press on Tender Point: Press lateral to medial.
Treatment : With patient prone, stand on the same side as the Tender Point.
For extension of the hip, place your knee on the table to support the patient's
thigh and abduct slightly.
High ilium Tender Point
Treatment position (HISI)
122 Published by OSTEOPATHIC PRESS, a division of TUCSON OSTEOPATHIC MEDICAL FOUNDATION
P 4 L GLUTEUS MAXIMUS Posterior 4th Lumbar
Location of Tender Point: One-and-a-half to two inches below the superior margin of the ilium,
slightly posterior to the border of the tensor fascia lata.
Anatomical Correlation: Superior lateral portion of the gluteus maximus.
Treatment Position): With patient prone, stand on the side opposite the Tender Point with your foot
on the table.
Hip extension is achieved by lifting the patient's leg on the side of the Tender Point and supporting
it on your thigh.
Adduct slightly more than with P 3 L. Grasp the patient's thigh and pull back on it to achieve
external rotation.
The higher your hand is on the thigh, the greater the rotation. Less rotation needed than with P 3 L.
POSTERIOR PELVIS & HIP
• GLUTEUS MEDIUS PAIN PATTERN IS SIGNIFICANT
FOR PAIN OVER SACRO-ILIAC JOINT AND SACRUM
GLUTEUS MEDIUS
Location of Tender Point:
On a line overlying the muscle along the lateral two-thirds of the crest of the ilium,
and within 1 -inch of the crest.
Treatment :With patient prone, stand on the same side as the Tender Point. Lift
extend the hip
grasp the anterior thigh.
Holding the thigh in extension,
moderately abduct, rotate internally as much as possible.
Clinical Correlation(s): Pain in the sacroiliac area, the sacrum area, the area
superior to the crest of the ilium, and the buttock area. Pain in one or two of
these areas usually is present.
.
Gluteus Medius treatmentneeds Int Rot, extension and
Abduction
POSTERIOR PELVIS & HIP
GLUTEUS MINIMUS HAS A VERY SIGNIFICANT PAIN REFERRAL PATTERN
IT CLOSELY MIMICS A RADICULOPATHY PICTURE
GLUTEUS MINIMUS
Location of Tender Point: The Tender Point of the gluteus minimus may be palpated
at two Points:
1) The anterior border of the gluteus minimus muscle, superior and anterior to
the greater trochanter.
2) Immediately posterior to the tensor fascia lata muscle about 1 inch below the
iliac crest, which is a more frequently encountered Point.
Myofascial pain pattern
Treatment Position: With patient prone or supine, depending on which Tender Point
you are treating, sit on a chair or stool, or stand, on the Tender Point side.
Flex the hip about 90°. Use slight abduction and marked internal rotation of the hip.
.
.
GLUTEUS MINIMUS
This is not found behind as I had
thought at first, but about two and a
half inches down and out from the
anterior superior spine of the ilium.
This and the gluteus medius are
common causes for pain on the
lateral part of the pelvis, after a long
drive in a car in a sitting position.
The weight is carried on the ischial
tuberosities and the greater
trochanters of the femurs hang
down in an external rotation strain.
A fairly marked femur flexion with
slight abduction and internal
rotation of the femur, produced by
pulling the foot more lateral than
the knee, will stop these.
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POSTERIOR LUMBAR SPINE
• Upper pole 5th - Multifidis & other muscles attaching to the sacrum & fascia overlying
XXX
Multifidus treatment needs Adduction and Extension
UP 5 L treatment needs Extension and Adduction
P 5 L MULTIFIDIS (Jones' Upper Pole 5)
Location of Tender Point: On the
superior medial surface of the posterior superior iliac spine.
Anatomical Correlation: Multifidis muscle in the upper sacral area.
Direction to Press on Tender Point: Press from posterior
medially to anterior laterally, against the superior medial surface
of the posterior superior iliac spine.
Treatment Position: With patient prone, stand on the side
opposite the Tender Point. Grasp the patient's thigh and pull
back to achieve hip extension.
Adduction and rotation are slight to moderate and achieved in
the same way. •-
Multifidis muscle
Multifidis on sacrum pain pattern
POSTERIOR LUMBAR SPINE
• THE LOWER POLE 5TH POINT IS THE ILIOPSOAS AS IT COMES ACROSS THE HIPJOINT AND THE RIM OF
THE PELVIS
Iliopsoas? (LP5L)
LP5L treatment needs Flex and Adduction
L P L 5
(Jones' Lower Pole)
Location of Tender Point
:1) About '/2-inch below the posterior superior iliac spine, in a
space between it and the posterior inferior iliac spine.
2) On the posterior superior aspect of the sacral base near the
midline.
Direction to Press on Tender Point: Press posterior to
anterior on either Point.
Treatment Position: With patient prone,
sit in a chair on the same side of the table
Drop the leg on the involved side off the table with the knee flexed
and the patient's ankle resting on your thigh.
Flex the hip to 90°to 100°. Adduct the patient's knee slightly by
pushing it medially under the table. •
.
Published by OSTEOPATHIC PRESS, a division of TUCSON OSTEOPATHIC MEDICAL FOUNDATION 121
POSTERIOR PELVIS & HIP
THE PIRIFORMIS PAIN PATTERN SHOWN ABOVE DOES NOT INCLUDE
THE PAIN THAT MIGHT BE PRODUCED BY PRESSURE ON THE SCIATIC
NERVE. SEE ANATOMICAL VARIATIONS ABOVE.
.
PIRIFORMIS
Location of Tender Point: Over the body of the piriformis muscle, 3-inches medial and
slightly cephalad to the greater trochanter.
Treatment Position: With patient prone, sit on a chair or stool on the same side as the
Tender Point.
Suspend the patient's leg on the Tender Point side off the table with the ankle resting on
your caudad thigh.
Flex the hip 120°to 1 30°. Abduction and internal rotation as needed.
Treatment position.
Piriformis pain pattern
Published by OSTEOPATHIC PRESS, a division of TUCSON OSTEOPATHIC MEDICAL FOUNDATION | 125
Sacrum
• The tender points are probably in the area of attachment of the
• multifidis, spinalis, logisstmus, iliocostalis muscles & overlying fascia
SACRUM P S 1
Location of Tender Point:
Approximately one-half inch medial to the inferior aspect of the posterior
superior iliac spine bilaterally.
Anatomical Correlation: Ligamentous or fascial patterns within the skeletal
structure; attachment of the multifidis, longissimus thoracis, and iliocostalis
lumborum.
Treatment Position: With patient prone, stand at the side of the table, usually
opposite the Tender Point.
Apply a very strong posterior to anterior pressure on the corner of the
sacrum, which is diagonally opposite the side of the Tender Point.
This produces a rotation around the oblique axis of the sacrum..
Sacral Tender Points
132 | Published by OSTEOPATHIC PRESS, a division of TUCSON OSTEOPATHIC MEDICAL FOUNDATION
SACRUM P S 2 and P S 3
Location of Tender Point:
Mid-line on the sacrum between the 1st and 2nd sacral spines.
Anatomical Correlation: Same as stated for P S 1.
Treatment Position: With patient prone, stand at either side of the table.
Apply strong pressure from posterior to anterior in the mid-line to
the apex of the sacrum.
This produces a rotation around the transverse axis of the sacrum.
Sacral Tender Points
Treatment position
Published by OSTEOPATHIC PRESS, a division of TUCSON OSTEOPATHIC MEDICAL FOUNDATION | 1 33
SACRUM P S 4
Location of Tender Point:
Mid-line on the sacrum just above the sacral hiatus and below the
3rd sacral spine.
Treatment Position(s): With patient prone,
stand at either side of the table.
Apply firm pressure from posterior to anterior in the mid-line on
the base of the sacrum.
This produces a rotation around the transverse axis of the sacrum.
1 34 | Published by OSTEOPATHIC PRESS, a division of TUCSON OSTEOPATHIC MEDICAL FOUNDATION
SACRUM P S 5
Location of Tender Point:
About one-fourth inch medial and one-fourth inch superior to the inferior
lateral angles of the sacrum bilaterally.
Anatomical Correlation: Same as with P S 1.
Treatment Position:
With patient prone, stand at the side of the table opposite the Tender Point.
Apply a posterior to anterior pressure on the corner of the sacrum
diagonally opposite the side of the Tender Point.
This produces a rotation around the oblique axis of the sacrum.
Sacral Tender Points
Treatment position
Published by OSTEOPATHIC PRESS, a division of TUCSON OSTEOPATHIC MEDICAL FOUNDATION | 135
COCCYGEUS (Coccyx Point)
Location of Tender Point: On either side of the tip of the coccyx.
Anatomical Correlation: Coccygeus muscle.
Direction to Press on Tender Point: Press from posterior lateral to anterior
medial.
Treatment Position): With patient prone,
Pressure is applied from posterior to anterior on the apex of the
sacrum.
While maintaining this pressure, the apex is rotated toward the side of the
Tender Point.
Occasionally, the rotation is away. •-
.Coccyx Tender Point
1 36 | Published by OSTEOPATHIC PRESS, a division of TUCSON OSTEOPATHIC MEDICAL FOUNDATION
Counterstrain for Sacral TorsionRamirez and Schwartz JAOA vol91 No3 March1991
• Define torsion: RonR; RonL;LonL;LonR
• Look for tender sacral foramen on axis side
• Place patient prone and sit on opposite side of tender sacral foramina
• Leg opposite tender points is abducted 30 degrees and flexed at the hip and the extended knee rests on your lap
• Apply pressure to opposite ilium with forearm 1
inch lateral to PSIS to relieve 75% of tenderness
Recommended